Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

GABAPENTIN 100 MG CAPSULE

Facility

$217.55

Service Code	NDC 60505011200
Hospital Charge Code	18309
Hospital Revenue Code	637
Min. Negotiated Rate	$137.06
Max. Negotiated Rate	$195.80
Rate for Payer: Aetna Commercial	$184.92
Rate for Payer: Aetna New Business (MI Preferred)	$141.41
Rate for Payer: Cash Price	$174.04
Rate for Payer: Cofinity Commercial	$152.28
Rate for Payer: Cofinity Commercial	$187.09
Rate for Payer: Cofinity Medicare Advantage	$152.28
Rate for Payer: Encore Health Key Benefits Commercial	$174.04
Rate for Payer: Healthscope Commercial	$195.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$184.92
Rate for Payer: PHP Commercial	$184.92
Rate for Payer: Priority Health Cigna Priority Health	$141.41
Rate for Payer: Priority Health SBD	$137.06

GABAPENTIN 100 MG CAPSULE

Facility

$178.60

Service Code	NDC 00904666561
Hospital Charge Code	18309
Hospital Revenue Code	637
Min. Negotiated Rate	$112.52
Max. Negotiated Rate	$160.74
Rate for Payer: Aetna Commercial	$151.81
Rate for Payer: Aetna New Business (MI Preferred)	$116.09
Rate for Payer: Cash Price	$142.88
Rate for Payer: Cofinity Commercial	$125.02
Rate for Payer: Cofinity Commercial	$153.60
Rate for Payer: Cofinity Medicare Advantage	$125.02
Rate for Payer: Encore Health Key Benefits Commercial	$142.88
Rate for Payer: Healthscope Commercial	$160.74
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$151.81
Rate for Payer: PHP Commercial	$151.81
Rate for Payer: Priority Health Cigna Priority Health	$116.09
Rate for Payer: Priority Health SBD	$112.52

GABAPENTIN 100 MG CAPSULE

Facility

$183.30

Service Code	NDC 63739059110
Hospital Charge Code	18309
Hospital Revenue Code	637
Min. Negotiated Rate	$115.48
Max. Negotiated Rate	$164.97
Rate for Payer: Aetna Commercial	$155.80
Rate for Payer: Aetna New Business (MI Preferred)	$119.14
Rate for Payer: Cash Price	$146.64
Rate for Payer: Cofinity Commercial	$128.31
Rate for Payer: Cofinity Commercial	$157.64
Rate for Payer: Cofinity Medicare Advantage	$128.31
Rate for Payer: Encore Health Key Benefits Commercial	$146.64
Rate for Payer: Healthscope Commercial	$164.97
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$155.80
Rate for Payer: PHP Commercial	$155.80
Rate for Payer: Priority Health Cigna Priority Health	$119.14
Rate for Payer: Priority Health SBD	$115.48

GABAPENTIN 100 MG CAPSULE

Facility

$305.50

Service Code	NDC 67877022205
Hospital Charge Code	18309
Hospital Revenue Code	637
Min. Negotiated Rate	$122.20
Max. Negotiated Rate	$274.95
Rate for Payer: Aetna Commercial	$259.68
Rate for Payer: Aetna Medicare	$152.75
Rate for Payer: Aetna New Business (MI Preferred)	$198.58
Rate for Payer: BCBS Complete	$122.20
Rate for Payer: Cash Price	$244.40
Rate for Payer: Cofinity Commercial	$213.85
Rate for Payer: Cofinity Commercial	$262.73
Rate for Payer: Cofinity Medicare Advantage	$213.85
Rate for Payer: Encore Health Key Benefits Commercial	$244.40
Rate for Payer: Healthscope Commercial	$274.95
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$259.68
Rate for Payer: PHP Commercial	$259.68
Rate for Payer: Priority Health Cigna Priority Health	$198.58
Rate for Payer: Priority Health SBD	$192.46

GABAPENTIN 100 MG CAPSULE

Facility

$305.50

Service Code	NDC 67877022205
Hospital Charge Code	18309
Hospital Revenue Code	637
Min. Negotiated Rate	$192.46
Max. Negotiated Rate	$274.95
Rate for Payer: Aetna Commercial	$259.68
Rate for Payer: Aetna New Business (MI Preferred)	$198.58
Rate for Payer: Cash Price	$244.40
Rate for Payer: Cofinity Commercial	$213.85
Rate for Payer: Cofinity Commercial	$262.73
Rate for Payer: Cofinity Medicare Advantage	$213.85
Rate for Payer: Encore Health Key Benefits Commercial	$244.40
Rate for Payer: Healthscope Commercial	$274.95
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$259.68
Rate for Payer: PHP Commercial	$259.68
Rate for Payer: Priority Health Cigna Priority Health	$198.58
Rate for Payer: Priority Health SBD	$192.46

GABAPENTIN 100 MG CAPSULE

Facility

$51.70

Service Code	NDC 69097081307
Hospital Charge Code	18309
Hospital Revenue Code	637
Min. Negotiated Rate	$20.68
Max. Negotiated Rate	$46.53
Rate for Payer: Aetna Commercial	$43.94
Rate for Payer: Aetna Medicare	$25.85
Rate for Payer: Aetna New Business (MI Preferred)	$33.60
Rate for Payer: BCBS Complete	$20.68
Rate for Payer: Cash Price	$41.36
Rate for Payer: Cofinity Commercial	$36.19
Rate for Payer: Cofinity Commercial	$44.46
Rate for Payer: Cofinity Medicare Advantage	$36.19
Rate for Payer: Encore Health Key Benefits Commercial	$41.36
Rate for Payer: Healthscope Commercial	$46.53
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$43.94
Rate for Payer: PHP Commercial	$43.94
Rate for Payer: Priority Health Cigna Priority Health	$33.60
Rate for Payer: Priority Health SBD	$32.57

GABAPENTIN 100 MG CAPSULE

Facility

$51.70

Service Code	NDC 69097081307
Hospital Charge Code	18309
Hospital Revenue Code	637
Min. Negotiated Rate	$32.57
Max. Negotiated Rate	$46.53
Rate for Payer: Aetna Commercial	$43.94
Rate for Payer: Aetna New Business (MI Preferred)	$33.60
Rate for Payer: Cash Price	$41.36
Rate for Payer: Cofinity Commercial	$36.19
Rate for Payer: Cofinity Commercial	$44.46
Rate for Payer: Cofinity Medicare Advantage	$36.19
Rate for Payer: Encore Health Key Benefits Commercial	$41.36
Rate for Payer: Healthscope Commercial	$46.53
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$43.94
Rate for Payer: PHP Commercial	$43.94
Rate for Payer: Priority Health Cigna Priority Health	$33.60
Rate for Payer: Priority Health SBD	$32.57

GABAPENTIN 100 MG CAPSULE

Facility

$217.55

Service Code	NDC 60505011200
Hospital Charge Code	18309
Hospital Revenue Code	637
Min. Negotiated Rate	$87.02
Max. Negotiated Rate	$195.80
Rate for Payer: Aetna Commercial	$184.92
Rate for Payer: Aetna Medicare	$108.78
Rate for Payer: Aetna New Business (MI Preferred)	$141.41
Rate for Payer: BCBS Complete	$87.02
Rate for Payer: Cash Price	$174.04
Rate for Payer: Cofinity Commercial	$152.28
Rate for Payer: Cofinity Commercial	$187.09
Rate for Payer: Cofinity Medicare Advantage	$152.28
Rate for Payer: Encore Health Key Benefits Commercial	$174.04
Rate for Payer: Healthscope Commercial	$195.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$184.92
Rate for Payer: PHP Commercial	$184.92
Rate for Payer: Priority Health Cigna Priority Health	$141.41
Rate for Payer: Priority Health SBD	$137.06

GABAPENTIN 100 MG CAPSULE

Facility

$178.60

Service Code	NDC 00904666561
Hospital Charge Code	18309
Hospital Revenue Code	637
Min. Negotiated Rate	$71.44
Max. Negotiated Rate	$160.74
Rate for Payer: Aetna Commercial	$151.81
Rate for Payer: Aetna Medicare	$89.30
Rate for Payer: Aetna New Business (MI Preferred)	$116.09
Rate for Payer: BCBS Complete	$71.44
Rate for Payer: Cash Price	$142.88
Rate for Payer: Cofinity Commercial	$125.02
Rate for Payer: Cofinity Commercial	$153.60
Rate for Payer: Cofinity Medicare Advantage	$125.02
Rate for Payer: Encore Health Key Benefits Commercial	$142.88
Rate for Payer: Healthscope Commercial	$160.74
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$151.81
Rate for Payer: PHP Commercial	$151.81
Rate for Payer: Priority Health Cigna Priority Health	$116.09
Rate for Payer: Priority Health SBD	$112.52

GABAPENTIN 100 MG CAPSULE

Facility

$183.30

Service Code	NDC 63739059110
Hospital Charge Code	18309
Hospital Revenue Code	637
Min. Negotiated Rate	$73.32
Max. Negotiated Rate	$164.97
Rate for Payer: Aetna Commercial	$155.80
Rate for Payer: Aetna Medicare	$91.65
Rate for Payer: Aetna New Business (MI Preferred)	$119.14
Rate for Payer: BCBS Complete	$73.32
Rate for Payer: Cash Price	$146.64
Rate for Payer: Cofinity Commercial	$128.31
Rate for Payer: Cofinity Commercial	$157.64
Rate for Payer: Cofinity Medicare Advantage	$128.31
Rate for Payer: Encore Health Key Benefits Commercial	$146.64
Rate for Payer: Healthscope Commercial	$164.97
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$155.80
Rate for Payer: PHP Commercial	$155.80
Rate for Payer: Priority Health Cigna Priority Health	$119.14
Rate for Payer: Priority Health SBD	$115.48

GABAPENTIN 300 MG CAPSULE

Facility

$277.30

Service Code	NDC 63739090310
Hospital Charge Code	18308
Hospital Revenue Code	637
Min. Negotiated Rate	$174.70
Max. Negotiated Rate	$249.57
Rate for Payer: Aetna Commercial	$235.70
Rate for Payer: Aetna New Business (MI Preferred)	$180.24
Rate for Payer: Cash Price	$221.84
Rate for Payer: Cofinity Commercial	$194.11
Rate for Payer: Cofinity Commercial	$238.48
Rate for Payer: Cofinity Medicare Advantage	$194.11
Rate for Payer: Encore Health Key Benefits Commercial	$221.84
Rate for Payer: Healthscope Commercial	$249.57
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$235.70
Rate for Payer: PHP Commercial	$235.70
Rate for Payer: Priority Health Cigna Priority Health	$180.24
Rate for Payer: Priority Health SBD	$174.70

GABAPENTIN 300 MG CAPSULE

Facility

$587.50

Service Code	NDC 67877022305
Hospital Charge Code	18308
Hospital Revenue Code	637
Min. Negotiated Rate	$235.00
Max. Negotiated Rate	$528.75
Rate for Payer: Aetna Commercial	$499.38
Rate for Payer: Aetna Medicare	$293.75
Rate for Payer: Aetna New Business (MI Preferred)	$381.88
Rate for Payer: BCBS Complete	$235.00
Rate for Payer: Cash Price	$470.00
Rate for Payer: Cofinity Commercial	$411.25
Rate for Payer: Cofinity Commercial	$505.25
Rate for Payer: Cofinity Medicare Advantage	$411.25
Rate for Payer: Encore Health Key Benefits Commercial	$470.00
Rate for Payer: Healthscope Commercial	$528.75
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$499.38
Rate for Payer: PHP Commercial	$499.38
Rate for Payer: Priority Health Cigna Priority Health	$381.88
Rate for Payer: Priority Health SBD	$370.12

GABAPENTIN 300 MG CAPSULE

Facility

$251.45

Service Code	NDC 00904666661
Hospital Charge Code	18308
Hospital Revenue Code	637
Min. Negotiated Rate	$158.41
Max. Negotiated Rate	$226.30
Rate for Payer: Aetna Commercial	$213.73
Rate for Payer: Aetna New Business (MI Preferred)	$163.44
Rate for Payer: Cash Price	$201.16
Rate for Payer: Cofinity Commercial	$176.02
Rate for Payer: Cofinity Commercial	$216.25
Rate for Payer: Cofinity Medicare Advantage	$176.02
Rate for Payer: Encore Health Key Benefits Commercial	$201.16
Rate for Payer: Healthscope Commercial	$226.30
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$213.73
Rate for Payer: PHP Commercial	$213.73
Rate for Payer: Priority Health Cigna Priority Health	$163.44
Rate for Payer: Priority Health SBD	$158.41

GABAPENTIN 300 MG CAPSULE

Facility

$251.45

Service Code	NDC 00904666661
Hospital Charge Code	18308
Hospital Revenue Code	637
Min. Negotiated Rate	$100.58
Max. Negotiated Rate	$226.30
Rate for Payer: Aetna Commercial	$213.73
Rate for Payer: Aetna Medicare	$125.72
Rate for Payer: Aetna New Business (MI Preferred)	$163.44
Rate for Payer: BCBS Complete	$100.58
Rate for Payer: Cash Price	$201.16
Rate for Payer: Cofinity Commercial	$176.02
Rate for Payer: Cofinity Commercial	$216.25
Rate for Payer: Cofinity Medicare Advantage	$176.02
Rate for Payer: Encore Health Key Benefits Commercial	$201.16
Rate for Payer: Healthscope Commercial	$226.30
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$213.73
Rate for Payer: PHP Commercial	$213.73
Rate for Payer: Priority Health Cigna Priority Health	$163.44
Rate for Payer: Priority Health SBD	$158.41

GABAPENTIN 300 MG CAPSULE

Facility

$277.30

Service Code	NDC 63739090310
Hospital Charge Code	18308
Hospital Revenue Code	637
Min. Negotiated Rate	$110.92
Max. Negotiated Rate	$249.57
Rate for Payer: Aetna Commercial	$235.70
Rate for Payer: Aetna Medicare	$138.65
Rate for Payer: Aetna New Business (MI Preferred)	$180.24
Rate for Payer: BCBS Complete	$110.92
Rate for Payer: Cash Price	$221.84
Rate for Payer: Cofinity Commercial	$194.11
Rate for Payer: Cofinity Commercial	$238.48
Rate for Payer: Cofinity Medicare Advantage	$194.11
Rate for Payer: Encore Health Key Benefits Commercial	$221.84
Rate for Payer: Healthscope Commercial	$249.57
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$235.70
Rate for Payer: PHP Commercial	$235.70
Rate for Payer: Priority Health Cigna Priority Health	$180.24
Rate for Payer: Priority Health SBD	$174.70

GABAPENTIN 300 MG CAPSULE

Facility

$587.50

Service Code	NDC 67877022305
Hospital Charge Code	18308
Hospital Revenue Code	637
Min. Negotiated Rate	$370.12
Max. Negotiated Rate	$528.75
Rate for Payer: Aetna Commercial	$499.38
Rate for Payer: Aetna New Business (MI Preferred)	$381.88
Rate for Payer: Cash Price	$470.00
Rate for Payer: Cofinity Commercial	$411.25
Rate for Payer: Cofinity Commercial	$505.25
Rate for Payer: Cofinity Medicare Advantage	$411.25
Rate for Payer: Encore Health Key Benefits Commercial	$470.00
Rate for Payer: Healthscope Commercial	$528.75
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$499.38
Rate for Payer: PHP Commercial	$499.38
Rate for Payer: Priority Health Cigna Priority Health	$381.88
Rate for Payer: Priority Health SBD	$370.12

GABAPENTIN 300 MG CAPSULE

Facility

$230.30

Service Code	NDC 63739023610
Hospital Charge Code	18308
Hospital Revenue Code	637
Min. Negotiated Rate	$92.12
Max. Negotiated Rate	$207.27
Rate for Payer: Aetna Commercial	$195.76
Rate for Payer: Aetna Medicare	$115.15
Rate for Payer: Aetna New Business (MI Preferred)	$149.70
Rate for Payer: BCBS Complete	$92.12
Rate for Payer: Cash Price	$184.24
Rate for Payer: Cofinity Commercial	$161.21
Rate for Payer: Cofinity Commercial	$198.06
Rate for Payer: Cofinity Medicare Advantage	$161.21
Rate for Payer: Encore Health Key Benefits Commercial	$184.24
Rate for Payer: Healthscope Commercial	$207.27
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$195.76
Rate for Payer: PHP Commercial	$195.76
Rate for Payer: Priority Health Cigna Priority Health	$149.70
Rate for Payer: Priority Health SBD	$145.09

GABAPENTIN 300 MG CAPSULE

Facility

$230.30

Service Code	NDC 63739023610
Hospital Charge Code	18308
Hospital Revenue Code	637
Min. Negotiated Rate	$145.09
Max. Negotiated Rate	$207.27
Rate for Payer: Aetna Commercial	$195.76
Rate for Payer: Aetna New Business (MI Preferred)	$149.70
Rate for Payer: Cash Price	$184.24
Rate for Payer: Cofinity Commercial	$161.21
Rate for Payer: Cofinity Commercial	$198.06
Rate for Payer: Cofinity Medicare Advantage	$161.21
Rate for Payer: Encore Health Key Benefits Commercial	$184.24
Rate for Payer: Healthscope Commercial	$207.27
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$195.76
Rate for Payer: PHP Commercial	$195.76
Rate for Payer: Priority Health Cigna Priority Health	$149.70
Rate for Payer: Priority Health SBD	$145.09

GABAPENTIN 400 MG CAPSULE

Facility

$148.05

Service Code	NDC 67877022401
Hospital Charge Code	18307
Hospital Revenue Code	637
Min. Negotiated Rate	$93.27
Max. Negotiated Rate	$133.24
Rate for Payer: Aetna Commercial	$125.84
Rate for Payer: Aetna New Business (MI Preferred)	$96.23
Rate for Payer: Cash Price	$118.44
Rate for Payer: Cofinity Commercial	$103.64
Rate for Payer: Cofinity Commercial	$127.32
Rate for Payer: Cofinity Medicare Advantage	$103.64
Rate for Payer: Encore Health Key Benefits Commercial	$118.44
Rate for Payer: Healthscope Commercial	$133.24
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$125.84
Rate for Payer: PHP Commercial	$125.84
Rate for Payer: Priority Health Cigna Priority Health	$96.23
Rate for Payer: Priority Health SBD	$93.27

GABAPENTIN 400 MG CAPSULE

Facility

$239.70

Service Code	NDC 63739098410
Hospital Charge Code	18307
Hospital Revenue Code	637
Min. Negotiated Rate	$95.88
Max. Negotiated Rate	$215.73
Rate for Payer: Aetna Commercial	$203.74
Rate for Payer: Aetna Medicare	$119.85
Rate for Payer: Aetna New Business (MI Preferred)	$155.80
Rate for Payer: BCBS Complete	$95.88
Rate for Payer: Cash Price	$191.76
Rate for Payer: Cofinity Commercial	$167.79
Rate for Payer: Cofinity Commercial	$206.14
Rate for Payer: Cofinity Medicare Advantage	$167.79
Rate for Payer: Encore Health Key Benefits Commercial	$191.76
Rate for Payer: Healthscope Commercial	$215.73
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$203.74
Rate for Payer: PHP Commercial	$203.74
Rate for Payer: Priority Health Cigna Priority Health	$155.80
Rate for Payer: Priority Health SBD	$151.01

GABAPENTIN 400 MG CAPSULE

Facility

$239.70

Service Code	NDC 63739098410
Hospital Charge Code	18307
Hospital Revenue Code	637
Min. Negotiated Rate	$151.01
Max. Negotiated Rate	$215.73
Rate for Payer: Aetna Commercial	$203.74
Rate for Payer: Aetna New Business (MI Preferred)	$155.80
Rate for Payer: Cash Price	$191.76
Rate for Payer: Cofinity Commercial	$167.79
Rate for Payer: Cofinity Commercial	$206.14
Rate for Payer: Cofinity Medicare Advantage	$167.79
Rate for Payer: Encore Health Key Benefits Commercial	$191.76
Rate for Payer: Healthscope Commercial	$215.73
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$203.74
Rate for Payer: PHP Commercial	$203.74
Rate for Payer: Priority Health Cigna Priority Health	$155.80
Rate for Payer: Priority Health SBD	$151.01

GABAPENTIN 400 MG CAPSULE

Facility

$272.60

Service Code	NDC 00904666761
Hospital Charge Code	18307
Hospital Revenue Code	637
Min. Negotiated Rate	$109.04
Max. Negotiated Rate	$245.34
Rate for Payer: Aetna Commercial	$231.71
Rate for Payer: Aetna Medicare	$136.30
Rate for Payer: Aetna New Business (MI Preferred)	$177.19
Rate for Payer: BCBS Complete	$109.04
Rate for Payer: Cash Price	$218.08
Rate for Payer: Cofinity Commercial	$190.82
Rate for Payer: Cofinity Commercial	$234.44
Rate for Payer: Cofinity Medicare Advantage	$190.82
Rate for Payer: Encore Health Key Benefits Commercial	$218.08
Rate for Payer: Healthscope Commercial	$245.34
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$231.71
Rate for Payer: PHP Commercial	$231.71
Rate for Payer: Priority Health Cigna Priority Health	$177.19
Rate for Payer: Priority Health SBD	$171.74

GABAPENTIN 400 MG CAPSULE

Facility

$272.60

Service Code	NDC 00904666761
Hospital Charge Code	18307
Hospital Revenue Code	637
Min. Negotiated Rate	$171.74
Max. Negotiated Rate	$245.34
Rate for Payer: Aetna Commercial	$231.71
Rate for Payer: Aetna New Business (MI Preferred)	$177.19
Rate for Payer: Cash Price	$218.08
Rate for Payer: Cofinity Commercial	$190.82
Rate for Payer: Cofinity Commercial	$234.44
Rate for Payer: Cofinity Medicare Advantage	$190.82
Rate for Payer: Encore Health Key Benefits Commercial	$218.08
Rate for Payer: Healthscope Commercial	$245.34
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$231.71
Rate for Payer: PHP Commercial	$231.71
Rate for Payer: Priority Health Cigna Priority Health	$177.19
Rate for Payer: Priority Health SBD	$171.74

GABAPENTIN 400 MG CAPSULE

Facility

$148.05

Service Code	NDC 67877022401
Hospital Charge Code	18307
Hospital Revenue Code	637
Min. Negotiated Rate	$59.22
Max. Negotiated Rate	$133.24
Rate for Payer: Aetna Commercial	$125.84
Rate for Payer: Aetna Medicare	$74.02
Rate for Payer: Aetna New Business (MI Preferred)	$96.23
Rate for Payer: BCBS Complete	$59.22
Rate for Payer: Cash Price	$118.44
Rate for Payer: Cofinity Commercial	$103.64
Rate for Payer: Cofinity Commercial	$127.32
Rate for Payer: Cofinity Medicare Advantage	$103.64
Rate for Payer: Encore Health Key Benefits Commercial	$118.44
Rate for Payer: Healthscope Commercial	$133.24
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$125.84
Rate for Payer: PHP Commercial	$125.84
Rate for Payer: Priority Health Cigna Priority Health	$96.23
Rate for Payer: Priority Health SBD	$93.27

GABAPENTIN 600 MG TABLET

Facility

$228.00

Service Code	NDC 00904682361
Hospital Charge Code	25855
Hospital Revenue Code	637
Min. Negotiated Rate	$143.64
Max. Negotiated Rate	$205.20
Rate for Payer: Aetna Commercial	$193.80
Rate for Payer: Aetna New Business (MI Preferred)	$148.20
Rate for Payer: Cash Price	$182.40
Rate for Payer: Cofinity Commercial	$159.60
Rate for Payer: Cofinity Commercial	$196.08
Rate for Payer: Cofinity Medicare Advantage	$159.60
Rate for Payer: Encore Health Key Benefits Commercial	$182.40
Rate for Payer: Healthscope Commercial	$205.20
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$193.80
Rate for Payer: PHP Commercial	$193.80
Rate for Payer: Priority Health Cigna Priority Health	$148.20
Rate for Payer: Priority Health SBD	$143.64

Know your out-of-pocket cost for care.

All Charges